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For ongoing operations in Afghanistan and Iraq, military medical personnel are among the first to arrive and the last to leave. Sustained U.S. involvement in these operations has placed stresses on the Department of Defense's (DOD) medical personnel. As the U.S. military role in Iraq and Afghanistan changes, the Army must adapt the number and mix of medical personnel it deploys. In response to Congress' continued interest in the services' medical personnel requirements in Iraq and Afghanistan, GAO evaluated the extent to which (1) DOD has assessed its need for medical personnel in theater to support ongoing operations, (2) the Army has adapted the composition and use of medical units to provide advanced medical care, and (3) the Army fills medical personnel gaps that arise in theater. To do so, GAO analyzed DOD policies and procedures on identifying personnel requirements, deploying medical personnel, and filling medical personnel gaps in Iraq and Afghanistan, and interviewed officials.

Medical officials in theater continually assess the number and the types of military medical personnel they need to support contingency operations in Iraq and Afghanistan and analyze the risks if gaps occur. Given congressional interest about deployed civilians, DOD reported to Congress in April 2010 that with each new mission, the need for new civilian skills has resulted in an increase in deployed civilians and that these civilians are not immune to the dangers associated with contingency operations. Although GAO did not learn of any DOD deployed civilians turned away for care in theater during this review, it is unclear the extent they can expect routine medical care in theater given that a DOD directive and theater guidance differ with regard to their eligibility for routine care. By clarifying these documents, DOD could reduce uncertainty about the level of routine care deployed DOD civilians can expect in theater and provide more informed insights into the military medical personnel requirements planning process. Army theater commanders have been reconfiguring or splitting medical units to cover more geographical areas in theater to better provide advanced emergency life-saving care quicker, but Army doctrine and the organizational design of these units, including needed staff, have not been fully updated to reflect these changes. Studies show that for those severely injured or wounded, 90 percent do not survive if advanced medical care is not provided within 60 minutes of injury. Officials in theater told GAO they are using specialized personnel documents to staff these medical units with more up-to- date personnel requirements to address gaps caused by splitting medical units, and that current doctrine and organizational design were not sufficient to address the capability needed for splitting medical units. According to an Army regulation, it maintains its lessons learned program to systematically update Army doctrine and enhance the Army's preparedness to conduct current and future operations. By updating Army doctrine and organizational documents for the design of medical units that could be used in other theaters, the Army could benefit from incorporating its lessons learned, where appropriate, and be better assured the current practice of splitting medical units to quickly provide advanced life-saving emergency medical care to those severely injured or wounded does not lead to unnecessary staffing challenges. Army commanders have used two approaches--cross-leveling and backfilling--to fill medical personnel gaps that arise in theater due to reasons such as illnesses, emergency leave, and resignations of medical personnel. When these gaps in needed medical personnel occur, the Army's 90-day rotation policy--while intended to ease the financial burden of deploying reserve medical personnel and help retain them--has presented some challenges in quickly filling these gaps in theater with reserve medical personnel when a medical provider is not able to deploy. However, Army data show the magnitude of these unfilled gaps or late arrivals for the reserve component medical providers ranged from about 3 percent to 7 percent from January 2008 to July 2010. GAO recommends that (1) DOD clarify the level of routine medical care that deployed DOD civilian employees can expect in theater and (2) the Army update its doctrine and the organizational design of split medical units. In response to a draft of this report, DOD generally concurred with the recommendations.

Recommendations for Executive Action

Status: Open

Comments: As of September 2014, DOD has not taken all the steps to close this recommendation. A DOD official stated that, as a result of changes in theater, there have been changes in guidance regarding medical care and they believe the guidance is clear, but they have not received guidance from Secretary of Defense directing them to clarify the level of care that deployed civilian employees can expect in theater, including their eligibility for routine care.

Recommendation: To better understand the extent to which deployed DOD civilian employees have access to needed medical care, as appropriate, the Secretary of Defense should direct the Combatant Commander of U.S. Central Command to clarify the level of care that deployed DOD civilian employees can expect in theater, including their eligibility for routine care.

Agency Affected: Department of Defense

Status: Open

Comments: As of September 2014, DOD has not taken all the steps to close this recommendation. However, DOD noted that there is an unquestionable need to formally update doctrinal publications. Army officials stated that lessons learned from Iraq and Afghanistan theater of operations and continuing performance efforts conducted by trauma systems and Army Medical Department Center and School, led to clear requirement to make fundamental changes to organizational design of the combat support hospital (CSH). Officials also stated that proposed changes to CSH incorporated into the force design update (FDU)--which is a method for changing designs of existing organizations and creating new design--increased, among other things, trauma care capabilities and numbers of medical personnel, physicians and critical care nurses. When the FDU is approved, the proposed first unit equipped is tentatively scheduled for fiscal year 2017. While the Army has taken actions to update its design and organizational design, we will need to confirm that the revised guidance specifically notes changes in the number and mix of medical specialists that make up the CSH (i.e., changes in its doctrine and organization of medical units concerning their size, composition and use). When we confirm what actions the Army has taken in response to this recommendation, we will provide updated information.

Recommendation: To enhance medical units' preparedness to conduct current and future operations given the changing use of combat support hospitals and forward surgical teams in Iraq and Afghanistan, the Secretary of the Army should direct the Army Medical Department to update its doctrine and the organization of medical units concerning their size, composition, and use.